1.

What medication is used following hip or knee surgery to prevent deep venous thrombosis (DVT)?

Low molecular weight heparin

2.

A 60-year-old woman presents with sudden, painless unilateral vision loss; what is the most worrisome condition?

Central retinal artery occlusion; any sudden vision loss requires emergent evaluation by slit lamp.

3.

What test is used to discern hip pain is from the sacroiliac joint vs the hip?

The FABER test (flexion, abduction, and external rotation of the hip) or Patrick test; pain in the sacroiliac area suggests sacroiliac joint dysfunction; pain may radiate to the groin.

4.

What is the first intervention for snakebite?

Antivenom

5.

An adult is hit in the face and has avulsed a tooth; how should it be handled?

Avoid touching tooth root; handle only by the crown; rinse with normal saline. If there is dirt or a large clot in the socket, perform gentle irrigation of the socket with normal saline. After implantation, have patient bite down on gauze while transporting to dentist. If unable to implant at scene, transport in Hanks solution, milk, or saline (not water) or the buccal sulcus if patient is alert and age-appropriate.

6.

How many days after stopping aspirin will the risk of bleeding persist?

5 days; most groups recommend 7 days

7.

For frostbite, what medications must be administered within the first 24 hours to lower amputation rates?

tPA to prevent thrombosis can lower the risk of amputation in frostbite.

8.

In infants and children, what clinical finding is the first sign of shock?

Tachycardia

9.

What ECG finding is suggestive of pericardial tamponade?

Electrical alternans (when consecutive QRS complexes alternate in height because of heart swinging in fluid) is seen in pericardial tamponade.

10.

What feature differentiates superficial and deep frostbite?

Deep frostbite finds tissue mottled and pulseless after rewarming, with loss of sensation and rare hemorrhagic blisters. Superficial frostbite has erythema and edema with rewarming and blister formation.

11.

When osteomyelitis is suspected, what is the test of choice?

Magnetic resonance imaging (MRI) is the most sensitive; leukocyte scans are also sensitive but not considered the first choice.

12.

What are the three categories of the Glasgow Coma Scale and its interpretation?

Eye opening (1-4)

Verbal response (1-5)

Motor response (1-6)

Score 12 indicates severe head injury, score 8 suggests the need for intubation and ventilation, and score 6 suggests the need for intracranial pressure monitoring.

13.

A young woman develops a cystic lesion over the posterior aspect of the wrist that becomes more prominent when the wrist is flexed and seems to diminish with wrist extension. What is the likely cause?

Ganglion cyst; they are filled with mucin and communicate with the adjacent joint space, tendon and/or tendon sheath via a stalk.

14.

In the postoperative period, what is the most common cause of fever?

Wound infection (not atelectasis)

15.

A patient falls on an outstretched hand and complains of wrist/base of thumb pain. The patient has tenderness within the anatomic snuff box, but the x-ray is read as normal. What do you do?

If no fracture is seen, scaphoid fracture cannot be ruled out. Repeat x-rays (including scaphoid views) should be obtained in 7-10 days. If negative and patient still has symptoms, obtain an MRI or bone scan.

16.

In wrist pain, tenderness in the anatomical snuffbox is associated with fracture of what bone?

Scaphoid (only 40% specific)

17.

What is the likely diagnosis in a patient with gum erythema, swelling, tenderness to touch, and edema? The gums bleed with brushing, flossing, or eating.

Acute gingivitis; often due to poor dental hygiene (secondary to plaque buildup). It is treated with chlorhexidine rinses, oral antibiotics (penicillins, metronidazole, doxycycline) and close follow-up with a dentist.

18.

How should the presence of an incidentally found thyroid nodule be evaluated?

A TSH should be done; if normal, an ultrasound of the thyroid should be obtained, followed by radionuclide scan (scintigraphy). If “hot,” no need for fine needle aspiration (FNA); if “cold” or patient is at high risk, do FNA.

19.

What tendons are involved in de Quervain tenosynovitis?

De Quervain tenosynovitis is an overuse injury of the wrist that involves abductor pollicis longus and extensor pollicis brevis tendons.

20.

What physical examination is used to diagnose de Quervain tenosynovitis?

De Quervain tenosynovitis is diagnosed by Finkelstein test (pain reproduced with folding the fingers over the thumb and passively deviating the thumb in an ulnar direction).

21.

In patients with acute onset right lower quadrant (RLQ) abdominal pain, what is the test of choice for diagnosing acute appendicitis?

Computed tomography (CT) scan

22.

Not long after starting a thiazide diuretic, a patient develops a painful, swollen, and erythematous knee without history of trauma; what is the likely diagnosis?

Gout often presents as an acute arthritis that can occur in the first metatarsophalangeal joint, mid-tarsal, ankle and knee joints. It is due to the deposition of monosodium urate (MSU) crystals that accumulate in joints and soft tissues resulting in acute and chronic arthritis, soft-tissue masses called tophi, urate nephropathy, and uric acid nephrolithiasis.

23.

What is the most sensitive method to determine a patient’s risk for postoperative bleeding?

A history of prior bleeding problems; not a laboratory evaluation

24.

How should hands that are soiled or contaminated with blood or bodily fluids be cleaned?

Hands should be initially washed using soap and water.

25.

Abdominal pain that seems out of proportion to findings on physical examination should suggest what condition?

Acute mesenteric ischemia

26.

What percentage of patients with incidentally found gallstones will ultimately need surgery?

Approximately 20% will progress to symptomatic disease requiring surgery.

27.

What is the implication on foot examination of slow (>2 seconds) capillary refill, thickened nails, and absence of hair on the toes?

Lower extremity arterial insufficiency

28.

What vitamin deficiencies are caused by gastric bypass?

Vitamin B₁₂, iron, calcium, and vitamin D

29.

What should be done in a patient with right upper quadrant (RUQ) abdominal pain consistent with biliary colic and a normal abdominal ultrasound?

A nuclear HIDA scan to identify acalculous cholelithiasis

30.

What areas of the body are common locations for superficial spreading malignant melanoma by gender?

Upper back for both men and women; lower extremities for women

31.

A skier goes to a mountain at 13,000 feet but becomes ill with a headache and nausea. What is the likely cause?

Acute mountain sickness, a form of high altitude sickness presents at over 8,000 feet of altitude (22% at 8,000; over 40% at 10,000), most often with headache and at least one of the following: Nausea/vomiting, fatigue/lassitude, dizziness, and/or difficulty sleeping. Symptoms begin 4-12 hours after ascent. For most, the symptoms are benign and self-limited.

32.

What is the diagnostic test for pulmonary embolism?

CT pulmonary angiography

33.

In what conditions should bilevel positive airway pressure (BiPAP) be deleterious?

Respiratory failure associated with sepsis, pneumonia, acute respiratory distress syndrome, or pneumothorax

34.

For acute dental infections, what is the antibiotic of choice?

Oral penicillin G

35.

A young male presents with acute right-sided chest pain; what test should be done to rule out spontaneous pneumothorax?

Chest x-ray

36.

In an acute epistaxis, what blood vessels are the most common cause?

Kiesselbach plexus located on the anteroinferior septum

37.

What component of blood is affected by aspirin ingestion?

Platelets are inhibited by aspirin.

38.

In what condition is BiPAP primarily used?

BiPAP is commonly used in chronic obstructive pulmonary disease (COPD). This addresses the progressive respiratory acidosis with impending respiratory failure or fatigue. BiPAP improves ventilation while decreasing Pco₂ levels.

39.

A patient complains of recurrent mid chest pain after eating. What condition is suggested by a dilated esophagus and an air-fluid level on chest x-ray?

Achalasia

40.

A 17-year-old female has a syncopal event after sprinting in a race. At the ED, her ECG demonstrated a prolonged QT interval. What are the dangers of long QT syndrome?

Long QT syndrome is due to a prolonged QTc and may precipitate polymorphic ventricular tachycardia (VT) (torsade de pointes), leading to dizziness, syncope, and sudden cardiac death from ventricular fibrillation (VF). Common causes for ventricular fibrillation include emotional stress, sudden exertion, and certain medications.

41.

What mechanism of injury causes radial head subluxation (nursemaid’s elbow) in a child?

Sudden traction of an extended arm

42.

How is radial head subluxation (nursemaid’s elbow) treated?

Grasp hand in handshake position; stabilize radial head with the other hand with the thumb over the radial head; in fluid motion, first supinate forearm then flex elbow

43.

What is the most common bacterial cause of community-acquired bacterial pneumonia in adults?

Streptococcus pneumoniae

44.

What is the causative agent in bacterial meningitis in college students?

Neisseria meningitidis

45.

What is spondylolysis?

Spondylolysis (defect or fracture within the pars interarticularis of the vertebral arch in the spinal column)

46.

A 27-year-old male who was recently started on olanzapine for bipolar disorder presents to the ED with high fever and confusion associated with muscle rigidity; what is the likely cause?

Neuroleptic malignant syndrome often presents within a few weeks of starting an offending medication (typically antipsychotics) with symptoms of fever, muscular rigidity, altered mental status, and autonomic dysfunction.

47.

What is spondylolisthesis?

Spondylolisthesis is the forward displacement of a vertebra, especially the fifth lumbar vertebra over S1, often due to a birth defect of the spine or acute trauma.

48.

How long may scaphoid fractures take before they are visible on radiographs?

2 weeks (up to 20% of x-rays will be falsely negative at the time of injury)

49.

Which structure is damaged in gamekeeper’s (or Skier) thumb?

The condition is an avulsion of the ulnar collateral ligament (UCL) where the ligament is torn at the proximal MCP of the thumb, either from a fall/trauma (Skier’s) causing an avulsion or chronic abduction (gamekeeper’s) causing lengthening of the UCL.

50.

Button battery ingestion in children should include what management?

If visible on x-ray in the esophagus, remove by immediate endoscopy. If it has passed into the stomach and either remains there more than 48 hours or the battery is larger than 2 cm in diameter, it should be removed endoscopically. If it has entered the duodenum, x-rays should be followed with expected expulsion within 72 hours.

51.

A patient with multiple sclerosis (MS) develops loss of vision over the course of a few days; what is the diagnosis?

Optic neuritis can develop for many reasons, but patients with MS are a higher risk. Symptoms include brow ache, globe tenderness, and deep orbital pain exacerbated by eye movement. Intravenous (IV) steroids are the treatment of choice; using oral steroids may increase the risk of recurrence.

52.

At what age would the presence of an undescended testicle prompt surgical evaluation?

6 months; surgery should be performed before 1 year of age. Surgery lowers risk of torsion and potential infertility, and lowers, but does not eliminate, risk of malignancy

53.

In patients with type 2 diabetes with hyperosmolar hyperglycemia, what is the initial treatment?

Intravenous fluids and insulin administration

54.

What is the most common site for diabetic patients to develop osteomyelitis?

The foot

55.

Which population has the greatest risk of developing melanoma?

Men over age 50

56.

What is paraphimosis?

Entrapment of the retracted foreskin; it is a medical emergency. Initial treatment includes applying ice to the region; definitive care involves a penile block followed by manual reduction.

57.

What is the most common component of gallstones?

Cholesterol

58.

What is the most common component of renal stones?

Calcium oxalate

59.

Increased urine acidity is associated with what type of stone?

Uric acid stones; treatment involves alkalinizing the urine.

60.

In a patient with recent head trauma, the finding of an air-fluid level in the sphenoid sinus should raise suspicion of what condition?

Basilar skull fracture

61.

In a patient with head trauma, double vision and fluid in the maxillary sinus are associated with what condition?

Orbital floor fracture

62.

What clinical findings and nerve distribution are involved in carpal tunnel syndrome?

Median nerve (palmar side of the thumb, the index and middle finger, and radial half of the ring finger)

63.

What condition should be considered in a patient who has just returned from a recent scuba diving trip with fatigue, anorexia, headache, and loss of sensation in the trunk area and lower extremities?

Decompression illness (the “bends”)

64.

What is the test of choice for the detection of symptomatic renal stones?

Unenhanced helical CT scan of the abdomen and pelvis; it is better than ultrasound.

65.

A few weeks following a viral infection, a patient presents with fatigue and hypotension; BP is 70/50 and heart sounds are muffled, with a friction rub. What is the most worrisome cause?

Post viral pericarditis that has induced a cardiac tamponade.

66.

A patient presenting with no history of trauma but with a “patch of blood” under the conjunctiva on the inferior aspect of the eye has what condition?

Subconjunctival hemorrhage; observation is the only treatment

67.

What rare condition is associated with an acute sphenoidal or ethmoidal sinusitis?

Cavernous sinus thrombosis

68.

What is the protocol for postexposure rabies prophylaxis for a dog bite if the dog cannot be observed?

Rabies immune globulin followed by human diploid cell rabies vaccine

69.

How is a pet hamster bite treated to prevent rabies?

Reassurance; bites from rabbits, squirrels, hamsters, guinea pigs, gerbils, chipmunks, rats, and mice almost never require antirabies treatment

70.

A 31-year-old female presents with daily episodes of recurrent vomiting. She assures you she is not bulimic, but does state she uses marijuana on a daily basis. What is the likely diagnosis?

Cyclic vomiting syndrome; chronic, idiopathic disorder characterized by recurrent, discrete episodes of disabling nausea and vomiting separated by symptom-free intervals lasting a few days to months. Chronic marijuana use is a common etiology.

71.

When a patient presents with multiple injuries in varying stages of healing, what diagnosis should be considered?

Physical abuse

72.

What is the normal range of the ankle-brachial index?

0.9-1.00 (ankle systolic pressure at rest is normally 90% of the brachial systolic pressure); <0.9 or above 1.4 is considered abnormal

73.

What clinical conditions should prompt an extensive evaluation when a DVT is diagnosed?

Age <50 with an idiopathic DVT, patients with recurrent DVT or pulmonary embolism, or patients with a family history of thromboembolism

74.

What scuba diving injury is common?

Barotrauma; when gas-filled space does not equalize its pressure with external pressure; sinuses, inner, middle and external ear, GI tract, lungs, etc., are all at risk.

75.

What type of arthropod can cause a bite that is initially a sharp pinprick sensation followed by resolution of the pain but systemic symptoms of cramping abdominal pain, muscle rigidity, sweating, nausea, vomiting, and shortness of breath?

Black widow spider envenomation

76.

What medication is the most potent and effective treatment for an acute asthma attack?

Corticosteroids

77.

When treating an acute asthmatic attack, what medications should be used as first-line therapy?

Short-acting β₂-agonists, and systemic steroids; antibiotics are not indicated unless a bacterial infection is suspected.

78.

What are the benefits of inhaled corticosteroids over oral steroids for the maintenance and control of asthma?

Inhaled corticosteroids have fewer systemic side effects like osteoporosis, cataracts, and adrenal insufficiency.

79.

Eye pain and photophobia are usually suggestive of what serious eye disorders?

Uveitis, keratitis, acute glaucoma, and orbital cellulitis

80.

What is the diagnosis when a patient has recurrent and severe spasmlike pain in the rectum?

Proctalgia fugax

81.

What is the most common diagnosis of a postmenopausal female with recurrent dysuria symptoms, blood on urinalysis, but negative urine cultures?

Interstitial cystitis

82.

What is the underlying condition when a patient presents with a shoulder pain with active and passive range of motion (frozen shoulder or adhesive capsulitis)?

Impingement syndrome of the rotator cuff

83.

What physical examinations are used to evaluate the integrity of the anterior cruciate ligament (ACL)?

Lachman test (knee is placed in 20 degrees of flexion and tibia is pulled anteriorly on a secured femur); a positive test result is indicated by increased tibial movement compared with the unaffected knee. The anterior draw test is slightly less sensitive, but easier to perform (knee flexed to 90 degrees and hip flexed to 45 degrees, interlock fingers behind the knee, using index fingers to assure hamstring relaxation). When pulling interiorly, extended translation of the tibia implies ACL tear.

84.

What is the treatment of choice for a patient who presents with pilonidal abscess?

Incision and drainage; ultimately evaluation for communicating sinus tracts

85.

What treatable condition is the most common cause for liver failure and transplantation in the United States?

Hepatitis C infection

86.

After a cardiac event, how long do cardiac troponins remain elevated?

Cardiac troponins may remain elevated for 2 weeks after an event.

87.

What noncardiac conditions may cause elevated troponin T levels?

Renal disease, polymyositis, or dermatomyositis

88.

Olecranon bursitis typically is due to what etiology?

Repeated trauma to the elbow

89.

What condition is associated with inflammation of the tendon sheath of the abductor pollicis longus and the extensor pollicis brevis?

De Quervain tenosynovitis

90.

A urine dipstick that is positive for hemoglobin but has no erythrocytes on microscopic examination is suggestive of what condition?

Rhabdomyolysis with myoglobinuria

91.

What are three hallmark symptoms in a patient with aortic stenosis?

Chest pain (angina), shortness of breath (dyspnea), and syncope

92.

What is the clinical and treatment difference between heat stroke and heat exhaustion?

Heat stroke is a medical emergency; the body temperature is usually greater than 40°C and sweating is usually absent; with heat exhaustion, there is profuse sweating and the body temperature does not exceed 40°C.

93.

A positive heterophile antibody test (monospot) is indicative of what infection?

Mononucleosis

94.

What clinical finding in mononucleosis may limit sports participation?

Splenomegaly; can last up to 6-8 weeks

95.

What disease is the most common cause of superior vena cava syndrome?

Carcinoma of the lung (especially small cell and squamous cell carcinoma)

96.

What are the key ECG findings seen in atrial fibrillation?

Absence of P waves and irregular ventricular rhythm. The atrial rate can range from 400 to 600 bpm, whereas the ventricular rate usually ranges from 80 to 180 bpm in the untreated state.

97.

What are the drugs of choice for patients with heart failure?

Angiotensin-converting enzyme inhibitor, β-blockers, if New York Heart Association class III or IV, aldosterone antagonists

98.

Recurrent hyperextension of the first toe that results in inflammation of the first metatarsophalangeal joint is called?

Turf toe

99.

What classes of antibiotics are commonly correlated with the development of Clostridium difficile colitis?

Penicillins, cephalosporins, and quinolones

100.

Atraumatic pain with abduction of the shoulder above 90 degrees is suggestive of what condition?

Rotator cuff tendonitis (impingement syndrome)

101.

Blunt foreign bodies can be observed in the esophagus for how long before endoscopic removal?

24 hours

102.

What is the appropriate treatment of a needlestick injury with a hollow bore needle that was used by an individual who is HIV negative?

Observation; copious irrigation; in cases where the exposure was from someone who is known to be HIV negative, no HIV prophylaxis is needed

103.

What common agents may result in false-positive urine drug screens?

Poppy seeds, Vicks inhalers, selegiline, nonsteroidal antiinflammatory drugs, rifampin, venlafaxine, dextromethorphan, oxaprozin, and fluoroquinolones

104.

What is the most common cause of death immediately following bariatric surgery?

Pulmonary embolism

105.

What are the body mass index (BMI) requirements for consideration of bariatric surgery in a type 2 diabetic?

In a Type 2 diabetic, bariatric (now called metabolic) surgery should be considered for a BMI of 40 kg/m² or greater, OR a BMI of greater than 30 kg/m² in a type 2 diabetic with poorly controlled disease

106.

What electrolyte imbalance results with excessive vomiting?

Hypokalemia, hypochloremia, metabolic alkalosis

107.

What test can help differentiate congestive heart failure (CHF) and COPD in acute dyspnea?

B-type natriuretic peptide (BNP); a BNP > 400 pg/mL has a high likelihood of CHF

108.

Individuals with acute onset worrisome chest pain and multiple cardiac risk factors benefit from what diagnostic procedure?

Cardiac catheterization

109.

In a patient with chest pain and has intermediate CV risk who is able to exercise and has a normal ECG, what is the diagnostic test of choice?

Treadmill exercise test

110.

What test should be considered in a patient with acute chest pain who is at intermediate risk of IHD and has an abnormal ECG (left bundle branch block, early repolarization, left ventricular hypertrophy, or digoxin use)?

Nuclear stress test or stress echocardiogram

111.

Knee pain that affects a quarter-sized area 2-6 cm below the medial joint line of the knee is likely what condition?

Pes anserine bursitis

112.

What are the most common infectious agents in acute epididymitis in men under age 35 years?

Chlamydia trachomatis or Neisseria gonorrhoeae

113.

In patients with what allergy history is influenza vaccine contraindicated?

Allergy to eggs

114.

What antiviral agents are effective for both influenza A and B?

Zanamivir (Relenza) and oseltamivir (Tamiflu)

115.

What is the most common infectious agent in acute epididymitis in men over age 35?

Coliform bacteria (i.e., Escherichia coli)

116.

What is the diagnostic test of choice to rule out acute testicular torsion?

Testicular ultrasound

117.

What is the most common cause of acute thyroid pain and tenderness?

Subacute thyroiditis usually related to a viral infection

118.

When is antibiotic therapy appropriate in the treatment of bacterial rhinosinusitis?

Only if symptoms have not improved after 10 days or if they worsen after 5-7 days

119.

On diagnostic paracentesis, what condition is consistent with ascitic fluid WBC count ≥500/mm³ with 50% polymorphonuclear leukocytes?

Acute bacterial peritonitis: WBC count ≥500/mm³ with at least 50% being PMNs, Protein count of >1 g/dL, Glucose < 50 mg/dL, LDH > 225 U/L

120.

What class of drugs is indicated for the treatment of status epilepticus?

Benzodiazepines

121.

A fracture of the proximal fifth metatarsal (Jones fracture) can be complicated by what condition?

Delayed union or nonunion

122.

In postoperative care, what is the major advantage of patient-controlled anesthesia (PCA)?

Avoidance of oversedation

123.

What are risk factors for drowning or near-drowning?

Male, between 1 and 5 years of age, low socioeconomic status, alcohol use

124.

What class of pain medication causes spasm of the sphincter of Oddi?

All opioid analgesics, including meperidine

125.

What narcotic pain medication has a neurotoxic metabolite that has the potential to accumulate and cause seizures, myoclonus, and tremors?

Meperidine (Demerol)

126.

What blood products are used in treating low fibrinogen levels and factor deficiencies such as hemophilia A and von Willebrand disease?

Cryoprecipitate

127.

Following acute head trauma, what test is used to detect a subdural hematoma?

Noncontrast CT

128.

What is the common cause of hot tub folliculitis?

Pseudomonas aeruginosa

129.

How much lung volume, in percent, can be treated with just observation in a spontaneous pneumothorax?

Up to 15%-20% of lung volume

130.

What emergency intervention is used to treat a tension pneumothorax?

Decompression with a large bore needle placed in the second intercostal space

131.

What high school sport is most commonly associated with concussion (traumatic brain injury)?

Football

132.

What nerve is compromised in carpal tunnel syndrome?

Median nerve

133.

In a newborn, what does a “double bubble” sign imply?

High or duodenal obstruction, including volvulus

134.

A patient presents after falling and hitting the head. What are the signs and symptoms of a concussion?

• 
  

  Confusion

  
  
• 
  

  Posttraumatic (antegrade) amnesia

  
  
• 
  

  Retrograde amnesia

  
  
• 
  

  Loss of consciousness (occurs in <10%)

  
  
• 
  

  Disorientation

  
  
• 
  

  Feeling “in a fog,” “zoned out”

  
  
• 
  

  Inability to focus (i.e., difficulty at work or school)

  
  
• 
  

  Delayed verbal and motor responses

  
  
• 
  

  Slurred/incoherent speech

  
  
• 
  

  Excessive drowsiness

135.

In a patient with acute abdominal pain, a positive psoas sign (pain with passive extension of the hip) and obturator sign (pain with internal and external rotation of the flexed hip) suggest what diagnosis?

Acute appendicitis

136.

What abnormal growth in the middle ear is associated with chronic otitis media, bony destruction, and perforation of the tympanic membrane?

Cholesteatoma, which is the formation of a squamous epithelial-lined sac in the middle ear

137.

For an uncomplicated laceration, how long should facial sutures be placed before removal?

3-5 days

138.

How long should sutures in areas subject to high tension be left in place?

10-14 days

139.

In a patient with blunt chest trauma, what radiographic test can be initially used to detect esophageal rupture (Boerhaave syndrome)?

Chest radiograph

140.

What classification of colon polyps are considered precancerous?

Villous adenomas

141.

What malignancy risk is increased in someone with a history of Peutz-Jeghers syndrome?

Colon cancer

142.

What clinical condition must be present to justify joint replacement surgery?

Intractable pain that does not respond to other medical treatment

143.

What type of malignant melanoma is most common?

Superficial spreading type

144.

What medication is used for life-threatening anaphylaxis?

Epinephrine

145.

Which type of melanoma has the poorest prognosis?

Nodular melanoma; these lesions tend to spread deeply into the underlying tissue.

146.

What blood type is the universal donor?

O-negative blood

147.

A fall on to an outstretched hand can cause injury to what complex?

Triangular fibrocartilage complex

148.

What is the current length of anticoagulation recommendations for an uncomplicated DVT of the calf?

3 months

149.

Following an initial immunization series through teenage years, how frequently should adults be immunized for tetanus prevention?

Every 10 years

150.

What blood pressure readings make a hypertensive crisis?

SBP > 179 mm Hg or a DBP > 109 mm Hg

151.

What are the treatment goals for a hypertensive crisis?

Goal: MAP lowered by maximally 20% or to DBP 100-110 mm Hg within first hour, then gradual reduction in BP to normal over next 48-72 hours

Drug of choice: nicardipine, clevidipine, or labetalol

152.

What dose, in mg/kg, is considered toxic in acetaminophen overdose?

>150 mg/kg acutely ingested

153.

What agent is used for acute acetaminophen overdose?

Administer N-acetylcysteine (NAC) based upon Rumack-Matthew nomogram.

NAC is virtually 100% hepatoprotective if initiated within 8 hours of an acute overdose.

154.

What arrhythmia is caused by a lightning strike?

Asystole; high-voltage alternating current may cause ventricular fibrillation.

155.

Who should be screened for an abdominal aortic aneurysm (AAA)?

The USPSTF recommends one-time screening for AAA with ultrasonography in men ages 65-75 years who have ever smoked.

156.

At what diameter should surgical repair of AAAs be offered?

5-6 cm (2005 ACC/AHA guidelines recommend repair when aneurysm is ≥5.5 cm.)

157.

What is the difference between Stage 1 and Stage 2 decubitus ulcer?

Stage 1: Nonblanchable erythema of intact skin

Stage 2: Partial-thickness dermal or epidermal skin loss causing a blister, shallow crater, or abrasion

158.

What is the difference between a Stage 3 and Stage 4 decubitus ulcer?

Stage 3: Full-thickness necrosis causing a deep crater down to the fascia

Stage 4: Full-thickness destruction of muscle, bone, or supporting structures

159.

A smoker has a raised white plaque on the buccal mucosa; what is the likely diagnosis?

Leukoplakia

160.

What is the risk of leukoplakia becoming cancerous?

Leukoplakia is benign. It is biopsied to confirm diagnosis, and can be used to encourage smoking cessation.

161.

Which local anesthetic has the longest duration of action?

Bupivacaine

162.

What locations should be avoided when injecting lidocaine with epinephrine?

Fingers, nose, penis, or toes (and ears)

163.

What topical agents may be used to treat chronic anal fissures?

Topical nifedipine with lidocaine gel

164.

A newborn who develops pneumonia in the lower segments of the upper lobes should be evaluated for what condition?

Tracheoesophageal fistula

165.

What are the clinical indications for Mohs surgery?

A patient with a nonmelanoma skin cancer measuring >2 cm, lesions with indistinct margins, recurrent lesions, and lesions close to important structures including the eyes, nose, and mouth

166.

At what level does lumbar disc disease occur?

L5-S1 interspace

167.

Following hip surgery, how long should DVT anticoagulation prophylaxis be continued?

At least 10-14 days postoperatively; some data suggest up to 35 days

168.

What size and location of kidney stone is best suited for treatment with lithotripsy?

If renal, <2 cm; if ureteral, <1 cm

169.

When should a preoperative antibiotic be administered?

Within 60 minutes of incision

170.

While playing basketball, a patient pivots off the knee, hears a loud “pop,” and develops immediate pain and swelling. What is the likely diagnosis?

Acute ACL injury and tear

171.

In what location do Morton neuromas arise?

The second and third interdigital space

172.

What tendon injury results in a mallet finger?

An injury to the extensor tendon at the DIP joint

173.

What tendon is injured in patients with a jersey finger?

Disruption of the flexor digitorum profundus tendon usually affecting the ring finger (75% of cases)

174.

What are the physiologic benefits of suturing?

Suturing approximates the skin and eliminates unnecessary dead space; tension is be minimized.

175.

What animal bites require rabies postexposure prophylaxis?

Bats, skunks, foxes, raccoons, and dogs (carnivores). You rarely need rabies prophylaxis for squirrels, hamsters, rabbits, gerbils, chipmunks, rats, or mice

176.

In a hypotensive patient, what is the drug of choice for bradycardia?

Atropine

177.

What class of drug is the first-line treatment for isolated systolic hypertension in the elderly?

Thiazide diuretics

178.

What drugs should be administered when first care is given to a patient with an unexplained altered mental status?

Administer naloxone, thiamine, and glucose

179.

What are the most common foods to induce anaphylaxis in children?

Milk, egg, wheat, soy, and peanuts

180.

If a patient on β-blockers develops anaphylaxis, epinephrine may be less effective; what drug should be used to treat anaphylaxis in these patients?

Glucagon

181.

What decision rule should be used to evaluate if an acute ankle sprain needs imaging?

The Ottawa Ankle Rules suggest that foot or ankle radiographs are unnecessary except when any of the following are present:

• 
  

  Bony tenderness at the posterior edge of the distal 6 cm of the tibia or tip of either malleolus

  
  
• 
  

  Bony tenderness along the base of the 5th metatarsal or navicular bone

  
  
• 
  

  Inability to take four unassisted steps both immediately after the injury and in the ED

182.

Treatment for mild to moderate ankle sprains should involve what sort of support?

Elastic bandage dressing coupled with an air stirrup splint

183.

What is the most common cause of chronic ankle pain?

Incomplete rehabilitation of an acute ankle sprain; physical therapy involving proprioception and strength training will often resolve.

184.

Organophosphate overdose is most commonly caused by what agents?

Pesticides

185.

What are the symptoms of organophosphate poisoning?

Organophosphates deactivate cholinesterases, resulting in excess acetylcholine. Symptoms include the following:

• 
  

  DUMBELS:

  
  
  
  
  • 
    

    Diarrhea/diaphoresis

    
    
  • 
    

    Urination

    
    
  • 
    

    Miosis/muscle fasciculations

    
    
  • 
    

    Bradycardia, bronchorrhea, bronchospasm

    
    
  • 
    

    Emesis

    
    
  • 
    

    Lacrimation

    
    
  • 
    

    Salivation

  
  
• 
  

  May have garlic odor

186.

An elderly patient presents with atraumatic joint pain, swelling, warmth, and decreased range of motion. What is the most important diagnosis to rule out?

Septic joint

187.

What is sudden onset unilateral loss of CN VII motor function (flaccid paralysis of facial muscles, including forehead) called?

Bell palsy

188.

Bell palsy is often induced by

Reactivation of latent herpesvirus, Lyme disease, atherosclerosis, diabetes, any recent viral infection, hypertension

189.

What bacterium is of concern in dog and cat bites?

Pasteurella multocida

190.

What is the antibiotic of choice for animal bites?

Amoxicillin-clavulanic acid

191.

In diabetic ketoacidosis (DKA), what are the mainstays of initial treatment?

IV hydration (1-2 L of NS over 1st hour)

IV insulin

Electrolyte correction

192.

What percentage of women in the ED are there due to a domestic violence-related injury?

14%-35%

193.

What is the cause of a bilateral facial erythematous rash that is associated with fever, often after a facial trauma?

Erysipelas is a distinct form of cellulitis notable for acute, well-demarcated, superficial bacterial skin infection with lymphatic involvement usually caused by Streptococcus pyogenes.

194.

What is the difference between periorbital cellulitis and orbital cellulitis?

Periorbital cellulitis is an acute bacterial infection of the skin and tissue anterior to the orbital septum; it does not involve orbital structures (globe, fat, and ocular muscles).

Orbital cellulitis is acute infection of orbital contents posterior to orbital septum; it results in decreased eye ROM because of infection.

195.

A patient presents with 2 weeks of chronic nonbloody diarrhea, but no other systemic symptoms. A wilderness camping trip a few weeks prior to the diarrhea onset is reported. What is the likely diagnosis?

Giardiasis

196.

What is the treatment of choice for giardiasis?

Metronidazole 250 mg PO TID for 5-7 days

197.

An elderly patient has a painful erythematous rash that follows a dermatomal distribution across the chest; you diagnose herpes zoster. What medications should be started within 72 hours of the rash’s emergence?

Oral antivirals should be started within 72 hours of skin lesion onset. Corticosteroids are NO LONGER used, as they do not decrease the risk of postherpetic neuralgia.

198.

A patient presents with a unilateral drooping eyelid; on examination, you notice the pupil on that side is smaller than the opposite side. What is the syndrome?

Horner syndrome presents as a classic triad of ipsilateral miosis, eyelid ptosis, and/or anhidrosis of the face and neck.

199.

Smokers who develop Horner syndrome should be tested for what tumor?

Smokers with Horner syndrome need to have a Pancoast tumor of the lung ruled out with at least a chest x-ray.

200.

An older patient has progressive lethargy, severe dehydration, electrolyte abnormalities, and a nonfasting glucose of >600 mg/dL but no ketones; what is the likely diagnosis?

Hyperosmolar hyperglycemic state; patient has undiagnosed type 2 diabetes mellitus with an insulin deficit. The resulting hyperglycemia acts as an osmotic diuretic, causing dehydration, an elevated serum osmolality, and relative hypernatremia (but no ketosis, as in DKA).

201.

A patient is hit in the eye during a fight and now presents with slight blurring of vision and “blood in my eye.” What is the diagnosis?

Hyphema; blood pools in anterior chamber (AC) of the eye (between iris and cornea), typically after some trauma to the region.

202.

A parent presents with a child who has pustules on the face; after they rupture, the lesions develop a golden appearance. What is the diagnosis?

Impetigo, a contagious, superficial, intraepidermal infection occurring prominently on exposed areas of the face and extremities; etiology is often Staphylococcus aureus alone or in combination with Group A β-hemolytic strep.

203.

What is the treatment of choice for mild to moderate impetigo?

Topical agents like mupirocin (Bactroban) 2% topical ointment or retapamulin 1% ointment; for more extensive infections, oral dicloxacillin may be used.

204.

Which patients should be treated for acute influenza with oral antivirals?

Those who present within 48 hours of symptom onset AND those with comorbidities (infants, elderly, those with asthma, COPD, cardiovascular disease, diabetes, etc.); those without comorbidities should be treated symptomatically.

205.

What condition is likely with sudden onset of vertigo (room spinning) when rolling over in bed or any change with regard to gravity that lasts for seconds to minutes?

Benign paroxysmal positional vertigo (BPPV) is a mechanical disorder of the inner ear characterized by a brief period of vertigo experienced when the position of the patient’s head is changed relative to gravity.

206.

What diagnostic maneuver is used to confirm the diagnosis of BPPV?

The Dix-Hallpike test (DHT) is used to diagnose BPPV. The patient is positioned in long-sitting on the exam table with the knees extended. If testing the right posterior canal, the head is rotated 45 degrees to the right. The patient is then lowered to supine position with the head 30-40 degrees below the horizontal, over the edge of the exam table for 45 seconds. The physician observes the direction of the fast phase of the nystagmus. The patient is then returned to the seated position, and the procedure is repeated toward the left.

207.

How do you perform Epley maneuver in the treatment of BPPV?

Canalith repositioning procedure (CRP) or Epley maneuver is used to treat BPPV. The clinician moves the patient through four provoking positions. The head is rotated toward the right (uninvolved side). Maintaining this head rotation, the patient is rolled onto the right side (uninvolved side) with the head slightly elevated from the supporting surface. The patient then sits up and flexes the neck 36 degrees. Each position is maintained for a minimum of 45 seconds or as long as the nystagmus lasts. The procedure is repeated three times.

208.

What conditions cause vertigo that lasts for hours or days?

TIA, stroke, seizures, new-onset multiple sclerosis, vestibular neuritis

209.

What electrolyte in DKA often appears incorrectly lowered?

Sodium; DKA induces a dilutional pseudohyponatremia.

210.

A breastfeeding mother is diagnosed with mastitis and placed on antibiotics. Can she continue to breastfeed?

Yes, mother and child are believed to be colonized with the same organism and the breast milk may be protective.

211.

Patients who develop struvite renal stones commonly have what in their history?

Urinary tract infections with urea-splitting bacteria

212.

What class of drugs increases the risk of floppy iris syndrome that can occur following cataract surgery?

Alpha antagonists, typically used to treat benign prostatic hypertrophy (BPH): alfuzosin (Uroxatral), doxazosin (Cardura), and tamsulosin (Flomax)